To be eligible to receive a Critical
Access Care Pharmacy Payment (CAP Payment), a pharmacy provider must:
Attest to meeting all the following
criteria for the entire previous fiscal quarter:
A) Pharmacy is physically located within
B) Pharmacy is brick and
mortar, meaning the pharmacy location is open to the public, recipients present
at the pharmacy to fill prescriptions, and the majority of the pharmacy's
business is not mail order based;
C) Pharmacy owners have an ownership or
control interest in fewer than 10 pharmacies; and
D) Pharmacy is located in a county with fewer
than 50,000 residents, or is located in a county with 50,000 or more residents
and in an area within Illinois that is designated as a Medically Underserved
Area by the Health Resources & Services Administration (HRSA), an agency of
the U.S. Department of Health and Human Services.
2) Submit an attestation to the Department
within 30 calendar days after the end of the fiscal quarter in a form and
manner prescribed by the Department.
b) CAP Payments for a fiscal year will be
made quarterly and may not exceed the lesser of $10,000,000 or the total amount
specifically appropriated to the Department for CAP Payments.
All CAP Payment calculations shall be
based on "CAP-Eligible Claims", which are defined as pharmacy claims:
1) Billed by an eligible CAP to a Managed
Care Organization (MCO) contracted with the Department for HealthChoice
Illinois, or its successor program, for dates of service during the quarter
2) Paid for by
the MCO; and
3) For which a paid
encounter claim record exists in the Department's Electronic Data Warehouse
(EDW) prior to 90 calendar days after the end of the quarter being
Individual CAP Payments will be made to individual pharmacy providers that meet
the requirements of subsection (a). Individual CAP Payment amounts are
calculated using the total number of the individual pharmacy's CAP-Eligible
Claims for the quarter being calculated multiplied by the lesser of:
1) The individual payment amount;
2) The Department's dispensing
fee for the medical assistance program in effect on April 1, 2018.
e) The "individual payment amount"
is equal to one quarter of the total amount appropriated for the CAP Program
for a fiscal year divided by the total number of CAP-Eligible Claims for the
quarter for all CAP pharmacies.
To ensure the proper distribution of CAP Payments under this Section, the
Department may conduct audits in accordance with 89 Ill. Adm. Code
Definitions. For purposes of this Section,
an "ownership or control interest" shall have the same meaning as a person with
an ownership or control interest as defined in